CHAP 14, 15, 16

• Vitamins


  are organic substances that are necessary for normal metabolic functions and for tissue growth and healing.
• Vitamin deficiencies lead to

  1. cellular and organ dysfunction
  2. slow recovery from illness
• Vitamins are frequently taken prophylactically rather than therapeutically.
• • Mega-doses of fat-soluble vitamins (A, D, E, and K) may cause toxic effects.

  ● Mega-doses of water-soluble vitamins are eliminated via the urine and thus are generally not toxic.
• Fat Soluble Vitamins

  ● ADEK

  ● metabolized slowly

  ● stored in fatty tissue, liver, and muscle in significant amounts

  ● excreted in the urine at a slow rate.
• Vitamin A


  for bone growth and the maintenance of epithelial tissues, skin, eyes, and hair.
• Vitamin D


  for calcium and phosphorus metabolism and is needed for calcium absorption from the intestines.
• Vitamin D2, ergocalciferol,


  a synthetic fortified Vitamin D
• Vitamin D3, cholecalciferol,


  a natural form of Vitamin D influenced by ultraviolet sunlight on the skin.
• Vitamin E


  with antioxidant properties that protect cellular components from being oxidized and red blood cells from hemolysis
• Vitamin K


  synthesis of prothrombin and the clotting factors VII, IX, and X.
• Vitamin K1 (phytonadione)


  -for oral anticoagulant overdose, only Vitamin K form available for therapeutic use and is most effective in preventing hemorrhage.
• Water Soluble Vitamins

  ● not stored by the body, so consistent, steady supplementation is required

  ● readily excreted in the urine.
• Thiamine (B1) Deficiency


  lead to the polyneuritis and cardiac pathology seen in Beriberi or to Wernicke encephalopathy that progresses to Korsakoff syndrome, conditions most commonly associated with alcohol abuse.
• Riboflavin (B2)


  for management of scaly dermatitis, cracked corners of the mouth, and inflammation of the skin and tongue.
• Niacin (B3)


  to alleviate Pellagra and hyperlipidemia.
• Pyridoxine (B6)


  alleviate the symptoms of neuritis caused by isoniazid (INH) therapy for tuberculosis, essential building block of nucleic acids, red blood cell formation, and synthesis of hemoglobin.
• Vitamin C (ascorbic acid)


  • absorbed from the small intestine
  • aids in the absorption of iron and in the conversion of folic acid.
  • not stored in the body and is excreted readily in the urine.
  • used in the treatment of Scurvy, which is rare in developed countries but seen in individuals who consume few fruits and vegetables.
• Folic acid


  • is essential for body growth and is needed for DNA synthesis
  • Without folic acid, cellular division is disrupted.
  • Folic acid deficiency - cause neural tube defects, such as spina bifida.
  • All women who may become pregnant consume 600 mcg of supplemental folic acid each day.
• Vitamin B12


  • aids in the conversion of folic acid to its active form
  • With active folic acid, Vitamin B12 promotes cellular division
  • also needed for normal hematopoiesis and maintains nervous system integrity.
  • intrinsic factor - produced by gastric parietal cells, helps in the absorption of Vitamin B12 through the intestinal wall
  • Vitamin B12 deficiency - Pernicious anemia
  • Deficiency can develop in strict vegetarians and those with malabsorption syndromes.
  • To correct Vitamin B12 deficiency, cyanocobalamin PO or IV
• Iron


  • for hemoglobin regeneration 60% of the iron in the body is in Hgb
  • Iron supplementation needed during pregnancy
• Copper


  • needed for the formation of RBCs and connective tissues.
  • prolonged copper deficiency may result in anemia that cannot be corrected by taking iron supplements
• Zinc

  • a trace element and important to many enzymatic reactions; important in growth, appetite, testicular maturation, skin integrity, mental activity, wound healing, and immunocompetence. Large amounts of zinc can be toxic.
• Chromium


  essential trace element that is required for proper carbohydrate, lipid, and nucleic acid metabolism in the human body.
• Selenium

  critical roles in reproduction, thyroid hormone metabolism, DNA synthesis, and protection from oxidative damage and infection
• ● Dehydration can occur in patients receiving enteral nutrition. Diarrhea is a common complication that can lead to dehydration.

  ● Aspiration pneumonitis is one of the most serious and potentially life-threatening complications of tube feedings.
• ● Parenteral nutrition (PN) is the administration of nutrients by a route other than the GI tract. If a patient is not eligible for enteral nutrition because of a nonfunctioning GI tract or intestinal failure, PN is delivered intravenously.

  ● High glucose concentrations are irritating to peripheral veins, so PN is administered through either a peripherally inserted central catheter (PICC) via the cephalic or basilica vein, or a central venous catheter via the subclavian or internal jugular vein; this depends on the tonicity of the concentration.
• ● Air embolism occurs when air enters into the central line catheter system. To prevent air embolism during dressing, cap, and tubing changes, ask the patient to turn their head in the opposite direction of the insertion site and to take a deep breath, hold it, and bear down.

  ● Strict asepsis is necessary when changing IV tubing and dressings at the insertion site.
• ● Hyperglycemia occurs primarily because of the hypertonic dextrose solution, but it also occurs when the infusion rate for PN is too rapid. In some cases, the pharmacist can add insulin to the PN solution if ordered by the provider.

  ● The sudden interruption of PN therapy can cause hypoglycemia; therefore, it is wise to keep a bag of 10% dextrose in the patient’s room. If the next bag of PN is late in arriving from the pharmacy, the bag of dextrose can be hung to avoid hypoglycemia.
• ● CNS – brain and spinal cord

  ● Stimulants – increase brain activity of CNS
• ADHD - dysregulation of specific neurotransmitters (dopamine, serotonin, norepinephrine)

  ● Children above 7

  ● Common: early adulthood, boys

  ● Characteristics: Inattentiveness, Inability to concentrate, Restlessness (fidgety), Hyperactivity (excessive and purposeless activity), Inability to complete tasks, Impulsivity
• Narcolepsy – sleeping disorder

  Major Groups of CNS Stimulants

  1. Amphetamines and caffeine – cerebral cortex
  2. Analeptics and caffeine – brainstem and medulla
  3. Anorexiants – hypothalamic and limbic areas
• Anorexiants

  ● Weight-loss attempts: nutritious diet, exercise, and behavior modification

  ● Reliance should be discouraged

  SE AR: Should not be given to children < 12 y/o Nervousness, Restlessness, Irritability, Insomnia, Heart problems, Hypertension
• Analeptics

  ● Stimulate respiration

  ● Xanthines (methylxanthines): caffeine citrate and theophylline

  Caffeine Citrate: neonatal apnea

  Theophylline: respiratory distress
• Insomnias - the inability to fall asleep or remain asleep
• Non-REM (NREM) Sleep

  ● Stage 1 (N1) - Llight sleep, where you drift in and out of sleep and can be easily awakened

  ● Stage 2 (N2) - deeper sleep stage, brain waves become slower with occasional bursts of rapid brain waves; eye movements stop, and heart rate and body temperature decrease.

  ● Stage 3 (N3) - deep sleep, slow-wave sleep; most restorative stage of sleep
• REM (Rapid Eye Movement) Sleep

  ● rapid eye movements, increased brain activity, and vivid dreams. Muscles become temporarily paralyzed, and heart rate and breathing become irregular;

  ● for memory consolidation and learning.
• Types of sedatives

  ● Short-acting hypnotics - useful in achieving sleep that allows patients to awaken early in the morning without any lingering side effects.

  ● Intermediate-acting hypnotics - useful for sustaining sleep; however, with residual drowsiness, or hangover, in the morning.

  ● Use short-term to prevent drug dependence and tolerance.

  ● Abrupt discontinuation can cause withdrawal symptoms.
• SE AR

  ● REM Rebound - vivid dreams and nightmares.

  ● Hangover - residual drowsiness resulting in impaired reaction time.

  ● Dependence - appearance of withdrawal symptoms.

  ● Tolerance- need to increase the dosage to obtain the desired effect.

  ● Excessive Depression - long-term use may result in CNS depression

  ● Respiratory Depression - suppression of respiratory center in medulla.

  ● Hypersensitivity- skin rashes
• Sedative-Hypnotics Categories

  • Barbiturates

  1. Long-acting barbiturate - Phenobarbital sodium
  2. Intermediate-acting barbiturate - Butabarbital sodium
  3. Short-acting barbiturate - Secobarbital sodium

  • Benzodiazepines - flurazepam
  • Nonbenzodiazepines - Zolpidem
  • Melatonin Agonists - Ramelteon